Domain-specific deficits in self-awareness and relationship to psychosocial outcomes after severe traumatic brain injury

A Transdiagnostic, Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI)

Psychopathology, including depression, anxiety, and post-traumatic stress, is a significant yet inadequately addressed feature of moderate-severe traumatic brain injury (TBI). Progress in understanding and treating post-TBI psychopathology may be hindered by limitations associated with conventional diagnostic approaches, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). The Hierarchical Taxonomy of Psychopathology (HiTOP) offers a promising, transdiagnostic alternative to psychiatric classification that may more effectively capture the experiences of individuals with TBI. However, HiTOP lacks validation in the TBI population. To address this gap, we administered a comprehensive questionnaire battery, including 56 scales assessing homogeneous symptom components and maladaptive traits within HiTOP, to 410 individuals with moderate-severe TBI. We evaluated the reliability and unidimensionality of each scale and revised those with psychometric problems. Using a top-down, exploratory latent variable approach (bass-ackwards modeling), we subsequently constructed a hierarchical model of psychopathological dimensions tailored to TBI. The results showed that, relative to norms, participants with moderate-severe TBI experienced greater problems in the established HiTOP internalizing and detachment spectra, but fewer problems with thought disorder and antagonism. Fourteen of the 56 scales demonstrated psychometric problems, which often appeared reflective of the TBI experience and associated disability. The Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI) model encompassed broad internalizing and externalizing spectra, splitting into seven narrower dimensions: Detachment, Dysregulated Negative Emotionality, Somatic Symptoms, Compensatory and Phobic Reactions, Self-Harm and Psychoticism, Rigid Constraint, and Harmful Substance Use. This study presents the most comprehensive empirical classification of psychopathology after TBI to date. It introduces a novel, TBI-specific transdiagnostic questionnaire battery and model, which addresses the limitations of conventional DSM and ICD diagnoses. The empirical structure of psychopathology after TBI largely aligned with the established HiTOP model (e.g., a detachment spectrum). However, these constructs need to be interpreted in relation to the unique experiences associated with TBI (e.g., considering the injury's impact on the person's social functioning). By overcoming the limitations of conventional diagnostic approaches, the HiTOP-TBI model has the potential to accelerate our understanding of the causes, correlates, consequences, and treatment of psychopathology after TBI.

Assessment of self-awareness after severe acquired brain injury: A systematic review and recommendations for a new classification of offline self-awareness

Impairment in self-awareness (ISA) is an important obstacle in neurorehabilitation of severe acquired brain injury (ABI) patients since it can cause failure in adopting adequate compensatory strategies, or the implementation of ineffective or dangerous behaviors. Accordingly, it should be assessed as early and accurately as possible, even if, to date, no consensus exists on how best to measure SA, and on its explanatory models. The present systematic review aimed to address: (a) to which extent ISA has been assessed in studies enrolling severe ABI patients; (b) whether studies on assessment of SA after severe ABI considered any explanatory models of SA and which measures have been utilized accordingly; (c) possible gaps or criticism in the extant research on severe ABI patients; and (d) to provide a novel proposal for SA assessment/classification based on the results and discussion from the systematic review conducted in this well selected population of patients. A systematic review was carried out in the databases PubMed, Web of Science and PsycINFO; 701 studies were retrieved and finally 54 met the inclusion criteria. Our review evidenced the paucity of studies on assessment of SA in patients with severe ABI that specified the model and the level of SA. Only a few measures of SA went beyond its intellectual and declarative aspects, thus hindering an exhaustive assessment and a full comprehension of SA. Accordingly, we propose a more comprehensive classification of offline anticipatory SA, with some important implications in the neurorehabilitation field. The review demonstrated the need of measuring SA beyond its declarative level, differentiating between declarative and real anticipatory SA, as well as of assessing SA at both offline and online levels.

Profiling self-awareness in brain injury rehabilitation: A mixed methods study

ABSTRACTImpaired self-awareness impacts outcomes for individuals with brain injury. Self-awareness is a complex construct, with little known about how its presentation differs across diagnostic groups, or how brain injury-related changes are expressed by individuals in the early phase post-brain injury. This study aims to identify differences and similarities in patterns of self-awareness between patients with different brain injury diagnoses, and provide a clinical account of how individuals with ABI describe changes to themselves arising from brain injury. This is a mixed methods retrospective cohort study involving an audit of medical files that included extraction of data from the Self-Awareness of Deficits Interview. Quantitative and qualitative techniques were used to analyse data from 173 participants. Individuals identified a range of brain injury-related impairments across domains, with greatest difficulty noted with linking impairments to functional implications and setting realistic goals. There were similarities and distinct differences in the expression of changes across diagnostic groups. Two main themes that aligned with self-awareness theory were identified from the data: 1/ Development of self-awareness; and 2/ Dimensions of self-awareness. These interrelated themes demonstrated the multifaceted nature of the clinical presentation of self-awareness, and highlight the need for an individualized approach to cognitive rehabilitation.

Awareness through relationships in individuals undergoing rehabilitation following acquired brain injury

AIM

This cross-sectional study investigated the association between self-awareness and quality of therapeutic relationships following acquired brain injury (ABI) while controlling for the potential impact of cognitive problems. It also aimed to investigate attachment as a potential moderator.

METHOD

83 adults with ABI were recruited alongside a key member of their community neurorehabilitation team. The Scale to Assess Therapeutic Relationships (STAR) was used to measure therapeutic relationship quality and attachment was measured using the Experiences in Close Relationships - Relationship Structure (ECR-RS) questionnaire. Awareness was measured using the Patient Competency Rating Scale (PCRS) and the Mayo-Portland Adaptability Inventory (MPAI-4) provided a measure of cognitive problems. The MPAI-4 also provided an additional measure of awareness.

RESULTS

A significant association between self-awareness and therapeutic relationships was found in some regression models such that higher-quality relationships were associated with better awareness, after controlling for the impact of cognitive problems. Neither childhood parental attachment nor participants' attachment towards their rehabilitation staff were moderators.

CONCLUSION

The observed associations between awareness in clients and therapeutic relationships with rehabilitation staff may have importance for rehabilitation in this context. Results highlight the value of continuing to prioritize the therapeutic relational environment in ABI rehabilitation and research.

The Cognitive Awareness Scale for Basic and Instrumental activities of daily living to measure self-awareness after acquired brain injury: Preliminary evidence of its validity

Objective: There is a crucial need for reliable tools to measure impaired self-awareness (ISA) in patients with acquired brain injury (ABI) across cognitive-functional domains. The aim of this study was to assess the psychometric properties of the Cog-Awareness ADL Scale, which is a novel self-proxy discrepancy method for measuring ISA in both basic and instrumental activities of daily living. Methods: This multicenter study included 54 patients (no-low ISA n = 33; severe ISA, n = 21) from four outpatient rehabilitation units in Málaga-Granada, Spain, and 51 healthy controls. The participants and proxy raters completed the Cog-Awareness ADL Scale and the Patient Competency Rating Scale (PCRS). Agreement between both scales was assessed using Spearman's correlations and the Bland-Altman plot. Group comparisons were made on measures of SA, cognitive abilities and demographic variables. Sensitivity and specificity were analysed by ROC curve analysis. Results: Convergent validity was supported by strong correlations with the PCRS and its subscales (rho's ranging from 0.51 to 0.80, p < 0.01 for all). The Bland-Altman plot confirmed measurement agreement (only 3.70% of the scores were outside the 95% limits). External validity was demonstrated by effectively discriminating between healthy controls and ABI patients with no-low and severe ISA on each discrepancy index while controlling for cognitive/demographic variables. The Cog-Awareness ADL Scale showed optimal diagnostic accuracy (AUC = 0.95, sensitivity = 0.90, specificity = 0.90). Conclusions: The Cog-Awareness ADL Scale proved to be a feasible, valid, and clinical tool to assess ISA across different cognitive-functional domains, in Spanish ABI-patients.

A literature review of outcome and treatment options after acquired brain injury: Suggestions for adult offenders using knowledge from the general population

BACKGROUND

Acquired brain injury (ABI) is a major health problem, often with negative effects on behaviour and mental health as well as cognition. Prevalence of ABI is exceptionally high among offenders and increases their re-offending risk. Information on risk factors for ABI and its outcomes among offenders that could guide effective treatment for them is, nevertheless, scarce and dispersed. However, there is a more substantial literature about the general population that could inform work with brain-injured offenders, especially when selecting for samples or subgroups with similar relevant characteristics, such as lower socio-economic status (SES), pre-injury lower tested intelligence score (<85) and pre-injury mental health problems.

AIMS

To explore brain injury data from non-offender samples of otherwise similar socio-economic and mental health and ability characteristics to offenders then, first, to describe their untreated outcomes and, secondly, outcomes after frequently used interventions in these circumstances, noting factors associated with their effectiveness.

METHOD

Three databases were systematically searched for the years 2010-2022; first, using terms for brain injury or damage and cognitive (dys)function, mental health or quality of life. Second, in a separate search, we used these terms and terms for interventions and rehabilitation. In the second review, studies were selected for clear, distinguishable data on age, sex, SES and lifestyle factors to facilitate inferences for offenders. A narrative analytical approach was adopted for both reviews.

RESULTS

Samples with characteristics that are typical in offender groups, including lower SES, lower pre-injury intelligence quotient (<85), prior cognitive impairments and prior mental health problems, had poorer cognitive and behavioural outcomes following ABI than those without such additional problems, together with lower treatment adherence. With respect to treatment, adequate motivation and self-awareness were associated with better cognitive and behavioural outcomes than when these were low or absent, regardless of the outcome measured.

CONCLUSIONS

More complex pre-injury mental health problems and social disadvantages typical of offenders are associated with poorer post-brain injury recovery. This paper adds to practical knowledge by bringing together work that follows specific outcome trajectories. Overall, succesful ABI-interventions in the general population that aim at pre-injury difficulties comparable to those seen among offenders, show that personalising injury-specific treatments and taking account of these difficulties, maximised positive outcomes.

The experience of traumatic brain injury in a culturally and linguistically diverse sample in Australia

PURPOSE

Individuals from culturally and linguistically diverse (CALD) backgrounds experience poorer outcomes following traumatic brain injury (TBI), including poorer quality of life. The reasons for these poorer outcomes are unclear. Therefore, this study aimed to qualitatively investigate the experience of injury, rehabilitation, and recovery amongst individuals from a CALD background following TBI.

MATERIALS AND METHODS

Fifteen semi-structured interviews were conducted, and qualitatively analysed using reflexive thematic analysis.

RESULTS

It was demonstrated that: (a) the cognitive and behavioural consequences of TBI were accompanied by stigma and loss of independence; (b) participants held many beliefs related to their TBI, ranging from bad luck to acceptance. Participants' personal values and beliefs provided strength and resilience, with many viewing the injury as a positive event in their lives; (c) participants were appreciative of the high standard of care they received in hospital and rehabilitation, although communication barriers were experienced; (d) many participants identified with Australian culture, and few believed their cultural background negatively impacted their experience of TBI; (e) external support, particularly from family, was considered central to recovery.

CONCLUSION

These findings offer insight into the challenges CALD individuals face and factors that may facilitate their recovery and improve functional outcomes.

Self-awareness and quality of relationships after acquired brain injury: Systematic review without meta-analysis (SWiM)

BACKGROUND

Relational aspects of self-awareness following Acquired Brain Injury (ABI) are increasingly being recognized. However, research underpinning the nature of the association between self-awareness and quality of relationships has yet to be synthesized.

METHOD

Searches, which were completed between February 2022 and February 2023, consisted of combining terms related to ABI, self-awareness, and quality of relationships. Data were analyzed using the Synthesis Without Meta-Analysis (SWiM) approach.

RESULTS

Associations between self-awareness and relationship quality across eight studies identified for this review differed in direction and significance. A more consistent pattern emerged, however, when studies assessing the quality of specific types of relationships i.e., spousal (N = 1) and therapeutic (N = 3), were compared to studies assessing the quality of a person's broader network of relationships (N = 4). In particular, good awareness was positively associated with the quality of specific relationships (r = 0.66) whereas it was negatively associated with the quality of a person's broader network of relationships (r = -0.35).

CONCLUSION

Results are discussed with consideration given to measures assessing the quality of specific relationships. In particular, such measures may tap into important patterns of interaction between two individuals, such as those related to attunement or communication, which may be valuable preconditions for improving awareness.

Development and feasibility testing of a psychoeducational tool to support the return to work (RTW) of individuals with traumatic brain injury (TBI): The RTW after TBI app

To document the development and clinician evaluation of a psychoeducational and support tool: the return to work after traumatic brain injury app (RTW after TBI app). Co-design of the app involved the collaboration of traumatic brain injury (TBI) /vocational rehabilitation (VR) expert researchers (n = 4) and lived experience co-designers (individuals with TBI who had previously returned to work; n = 4). Twelve TBI/VR clinician reviewers then evaluated the app. Content analysis of TBI/VR clinician reviewers' interviews revealed four themes: content, usability (functional ease of use), utility (applicability to RTW after TBI) and suggestions for improvements. All clinicians reported that they would use the RTW after TBI app in their clinical practice. Although several aspects were reported to potentially limit the app's appropriateness for some TBI clients, many feasible improvements were suggested to address limitations. These improvements aim to increase the utility of the app with a wider range of clients and extend its use to other settings. Future research should evaluate, in a clinical trial, the efficacy of the RTW after TBI app in supporting individuals with TBI and their vocational providers and optimizing RTW success.

Impairments in Physiological Reactivity to Emotive Stimuli After Traumatic Brain Injury: A Systematic Review of Skin Conductance and Heart Rate Variability Evidence

OBJECTIVE

To examine evidence of impairments in physiological reactivity to emotive stimuli following traumatic brain injury (TBI).

METHODS

A search of PsychINFO, CINAHL (Cumulative Index to Allied Health Literature), Web of Science, EMBASE (Excerpta Medica dataBASE), and Scopus databases was conducted from 1991 to June 24, 2021, for studies comparing changes in skin conductance or heart rate variability to emotive stimuli between adults with TBI and controls. Two reviewers independently assessed eligibility and rated methodological quality.

RESULTS

Twelve eligible studies examined physiological reactivity to laboratory-based emotive stimuli, which included nonpersonal pictures/videos, posed emotion, stressful events, and personal event recall. Overall, 9 reported evidence that individuals with TBI experience lower physiological reactivity to emotive stimuli compared with healthy controls, although the findings varied according to the type and valence of emotional stimuli and physiological parameter. Most studies using nonpersonal pictures or videos found evidence of lower physiological reactivity in TBI participants compared with controls.

CONCLUSIONS

Based on laboratory-based studies, individuals with TBI may experience lower physiological reactivity to emotive stimuli. Further research is needed to investigate physiological responses to personally relevant emotional stimuli in real-world settings and to understand the interplay between physiological reactivity, subjective experiences, and behavior.

Psychosocial assessment in brain injury: An international social work survey

OBJECTIVE

To survey social workers in the field of traumatic brain injury (TBI)/acquired brain injury (ABI) about their practice in conducting psychosocial assessments. Design: A cross-sectional quality assurance study.

DESIGN

A cross-sectional quality assurance study.

PARTICIPANTS

Social workers from professional social work rehabilitation networks spanning Sweden, the United Kingdom, North America, and Asia Pacific regions.

MEASURE

Purpose-designed survey comprising closed and open items, organized into six sections and administered electronically.

RESULTS

The 76 respondents were mainly female (65/76, 85.5%) from nine countries (majority from Australia, United States, Canada). Two-thirds of respondents were employed in outpatient/ community settings (51/76, 67.1%), with the balance working in inpatient/rehabilitation hospital settings. Over 80% of respondents conducted psychosocial assessments, with the assessments informed by a systemic focus, situating the individual within their broader family and societal networks. The top five issues identified in inpatient/rehabilitation settings were housing related needs, informed consent for treatment, caregiver support, financial issues and navigating the treatment system. In contrast, the leading issues identified in community settings related to emotional regulation, treatment resistance and compliance issues, depression, and self-esteem.

DISCUSSION

Social workers assessed a broad range of psychosocial issues spanning individual, family, and environmental contextual factors. Findings will contribute to future development of a psychosocial assessment framework.

Psychosocial functioning mediates change in motor and cognitive function throughout neurorehabilitation for adults with acquired brain injury (ABI-RESTaRT)

OBJECTIVES

This study aimed to evaluate the mediational role of change in psychosocial abilities, adjustment and participation on change in motor and cognitive function from admission to discharge from a staged community-based brain injury rehabilitation (SCBIR) service in Western Australia, 2011-2020.

METHODS

A retrospective cohort study of n = 324 adults with ABI enrolled in SCBIR using routinely collected rehabilitation outcome measures data. Motor and cognitive function were assessed with the UK Functional Independence and Assessment Measure and psychosocial function with the Mayo-Portland Adaptability Inventory-4. Six multilevel mediation regression analyses were conducted to determine whether change in psychosocial function (abilities, adjustment and participation) mediated change in motor and cognitive function from admission to discharge.

RESULTS

Participants demonstrated clinically significant improvements in both motor (+ 11.8, p < 0.001) and cognitive (+ 9.5, p < 0.001) functioning from admission to discharge. Statistically significant improvements in psychosocial abilities (- 4.8, p < 0.001), adjustment (- 2.9, p = 0.001) and participation (- 2.5, p < 0.001) were also seen but were not clinically significant. Mediation analyses showed that participation accounted for 81% of improvements in motor function at discharge and 71% of cognitive function improvements. Adjustment accounted for 26% and 32% of change in motor and cognitive function, respectively. Abilities accounted for 60% of change in cognitive function but did not significantly influence change in motor function. Changes in psychosocial participation fully mediated change in motor function during neurorehabilitation.

CONCLUSIONS

Psychosocial function, particularly participation, is an important driver of motor and cognitive recovery throughout neurorehabilitation. Functional rehabilitation programs should target psychosocial improvement as an important mechanism of change.

Self-concept 6 months after traumatic brain injury and its relationship with emotional functioning

This is an observational exploratory study assessing self-concept and its association with depression, anxiety, satisfaction with life, and quality of life 6 months after experiencing a traumatic brain injury. Participants were 33 patients who suffered a traumatic brain injury 6 months before the assessment. The measures used in this study were the Repertory Grid Technique, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Satisfaction With Life Scale, and the Quality of Life after Brain Injury. We calculated Euclidean distances to assess differences in pre-and post-injury self-perception, as well as the proportion of opposed pole construct rating and polarization to understand how they are associated with the scores of the other offered measures. We found that the distance between the present and ideal self, as well as the distance between the present self and the self before the lesion showed moderate positive correlations with depression, and negative correlations with satisfaction with life and quality of life. Also, for the present and self before the lesion, the proportion of opposed pole ratings was correlated with depression symptoms, quality, and satisfaction with life, while for the present self and the ideal self this proportion was correlated with all the measures. The proportion of polarization of the present self and the total polarization was negatively correlated with symptom measures. The repertory grid might facilitate a greater understanding of self-concept after traumatic brain injury. This information could be used to guide treatments that address the emotions related to distances observed in the perception of the self.

Anosognosia in moderate-to-severe traumatic brain injury: A review of prevalence, clinical correlates, and diversity considerations

METHOD

A comprehensive search of peer-reviewed articles was conducted from September to November 2020 using Google Scholar and PubMed databases. Key terms included "anosognosia," "self-awareness," "traumatic brain injury," and variants thereof. Our search was restricted to articles published in English within the last 25 years, although a few historical articles were included due to scientific merit. Articles were chosen based on methodological quality, inclusion of solely or predominantly msevTBI sample, and relevance to the current topic.

CONCLUSIONS

Anosognosia is a multifaceted and domain-specific construct that affects the majority of those with msevTBI. It is related to TBI severity, injuries in right-hemispheric and cortical midline regions, specific aspects of executive function, psychological function, and cultural factors. We offer pragmatic advice for clinicians working with this population and discuss implications for the field regarding "best practices" of anosognosia assessment and intervention.

Impaired self-awareness and denial of disability in a community sample of people with traumatic brain injury

PURPOSE

To examine the nature and severity of impaired self-awareness (ISA) and denial of disability (DD) in a community-dwelling traumatic brain injury (TBI) population. Additionally, to investigate reliability, internal consistency, and feasibility of the Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD).

MATERIALS AND METHODS

ISA and DD were studied using the CRS-ISA-DD in a cross-sectional study with 78 TBI patients (3.1 years post-injury).

RESULTS

42% of individuals approached consented to participate in this study. Most participants showed one or more symptoms of ISA and DD, but severity scores were in the lower range (ISA: 13.2 ± 16.2; DD: 9.4 ± 10.7). The CRS-ISA-DD takes <10 min to complete, has excellent inter-rater reliability (ISA: ICC(2,1) = 0.928; DD: ICC(2,1) = 0.835), and acceptable-good internal consistency (ISA: α = 0.819; DD: α = 0.645). ISA severity correlated with neuropsychological test scores (r_s = -0.30 to -0.47) and injury severity. DD severity correlated with anxiety (r_s = -0.22) but not with avoidance coping or defense mechanisms.

CONCLUSIONS

Low levels of ISA and DD occurred in this sample of TBI patients. The CRS-ISA-DD is a reliable and feasible instrument. We recommend using it as a diagnostic tool to differentiate between ISA and DD once self-awareness problems have been identified.IMPLICATIONS FOR REHABILITATIONUnawareness of deficits can persist into the chronic stage when rehabilitation treatment has ended.The two main factors of unawareness, impaired self-awareness and denial of disability, are related to different neurological and psychological mechanisms.The Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD) can be used to distinguish the two main factors of unawareness.

Clinician reports of self-awareness after traumatic brain injury: a retrospective chart review

BACKGROUND

Impaired self-awareness (i.e., a lack of insight) is experienced by most individuals who have sustained a moderate to severe traumatic brain injury (TBI). During the early recovery period post-injury, these individuals may not be able to recognize their abilities and limitations, hence, negatively impacting their daily life and function. Although there are assessments and interventions to improve self-awareness after TBI, little is known about how clinicians assess and address this impairment in an inpatient rehabilitation setting.

OBJECTIVE

To examine how clinicians assess, report, and provide interventions for impaired self-awareness after TBI.

METHODS

A retrospective chart review was conducted on interdisciplinary rehabilitation clinician entries for individuals with TBI (n = 67) who received inpatient rehabilitation within a five-year period (2014-2019). A reflexive thematic analysis was used to identify themes pertaining to self-awareness.

RESULTS

Three themes were generated to explore clinician responses to their clients' impaired self-awareness: 1) 'recalling and understanding' described clinician observations of client behaviors and expressions of self-awareness, 2) 'applying and analyzing' identified clinicians providing relevant tasks and advice to clients, and 3) 'evaluating and creating' described clinicians actively interacting with clients by providing feedback, guided prompts, and a follow-up plan.

CONCLUSION

Clinicians produced varied responses to clients' impaired self-awareness after TBI. Findings may help to develop research priorities and integrated knowledge translation initiatives to increase evidence-based practice for impaired self-awareness after TBI.

Revisiting the dynamic comprehensive model of self-awareness: a scoping review and thematic analysis of its impact 20 years later

This study aimed to (1) describe the scope of research related to the Dynamic Comprehensive Model of Awareness (DCMA) (Toglia & Kirk, 2000); (2) identify themes and support for key model postulates; and (3) suggest future research directions related to this model. Using PRISMA scoping guidelines, 366 articles were reviewed, and 54 articles met our inclusion criteria. Selected studies were clustered into three themes: (1) the relationship between general and online self-awareness (50%); (2) interventions based on the model (41%); and (3) factors contributing to self-awareness (9%). Most studies were conducted with participants with acquired brain injury (BI) and traumatic BI (68%), most used a cross-sectional design (50%), and most intervention studies utilized a single-subject design (18%), followed by an experimental design (9%). This review provides evidence for the wide application of the DCMA across varying ages and populations. The need for a multidimensional assessment approach is recognized; however, stronger evidence that supports a uniform assessment of online self-awareness is needed. The intervention studies frequently described the importance of direct experience in developing self-awareness; however, few studies compared how intervention methods to influence general versus online self-awareness, or how cognitive capacity, self-efficacy, psychological factors, and context, influence the development of self-awareness.

Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model

We investigated the relationships between cognitive change following stroke, awareness of cognitive impairments, and mood to further understanding of change processes influencing psychological outcomes post-stroke in line with the "Y-shaped" process model. Patients (n = 143; M_age = 73 years, SD = 13.73; 74 males) were assessed at 3-weeks (T1) and 6-months (T2) post-stroke and had completed the Oxford Cognitive Screen (T1 and T2), the Cognitive Failures Questionnaire (CFQ; T2), and the Hospital Anxiety and Depression Scale (HADS; T2). An ANCOVA controlling for disability relating to activities of daily living (ADL) revealed that awareness of cognitive impairment was significantly lower in participants with moderate-severe cognitive impairment. Regression analysis indicated that greater awareness of cognitive impairment and reduced independence in ADL were associated with greater emotional distress at T2. Cognitive improvement was associated with lower emotional distressat T2. Contrary to the awareness hypothesis, moderation analyses suggest that this effect was largest for those most cognitively impaired at T1. Findings emphasize the importance of monitoring stroke patients' capacity to be self-aware when assessing and formulating long-term post-stroke distress and have potential implications for improving long-term emotional status in those most cognitively impaired post-stroke, e.g., through psychoeducation, cognitive rehabilitation, and emotional support.

Client experiences with holistic neuropsychological rehabilitation: "It is an ongoing process"

The effectiveness of holistic neuropsychological rehabilitation for people with acquired brain injury has previously been demonstrated by means of standardized and routinely administered outcome measures. However, the most important outcomes from the perspective of former clients are largely unknown. This study explored the experience of participating in a holistic neuropsychological rehabilitation programme by conducting three focus groups with twelve former clients who had sustained a brain injury. Data were transcribed verbatim and analysed using thematic analysis. "It is an ongoing process" emerged as the overarching theme for the experience of recovery from brain injury. Four subthemes, or phases, were identified. Participants went through (1) a phase of confrontation, after which they (2) trained their skills and strategies, and (3) experimented with these in daily life. In the end, clients reached a phase of (4) coming to terms with their injury. Participants described increased levels of self-esteem, sense of competence, and adaptation as the most important outcomes of the programme, as these factors helped them regain a sense of identity. The results indicate that including these factors in outcome evaluations of complex interventions after brain injury may be important as they appear essential for capturing the client's perspective on change.

Impaired self-awareness after traumatic brain injury: A systematic review. Part 2. Consequences and predictors of poor self-awareness

BACKGROUND

Impaired self-awareness (ISA) has frequently been found both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

This is the second of a two-part systematic review on ISA after TBI, focusing on the consequences and predictors of ISA after TBI.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included; 46 were specifically related to this second part of the review.

RESULTS

Among 16 studies that investigated the effect of ISA on outcome, most (n=13) found poor self-awareness associated with poor rehabilitation, functional, social and vocational outcome and with increased burden on relatives. Multiple factors have been found associated with increased frequency of ISA. ISA was found significantly related to injury severity in 8 of 10 studies, impaired executive functions in 12 of 15 studies, and poor social cognition in 3 studies, but paradoxically inverse associations were repeatedly found between self-awareness and emotional status (11 of 12 studies). Finally, although research in the field is still scarce, ISA seems associated with a dysfunction within brain networks involving the anterior cingulate cortex, anterior insula and fronto-parietal control network.

CONCLUSIONS

ISA is a complex and multifaceted disorder associated with poor rehabilitation outcome, severe injuries, and deficits of executive functions and social cognition but has an inverse association with mood impairments.

Impaired self-awareness after traumatic brain injury: a systematic review. Part 1: Assessment, clinical aspects and recovery

BACKGROUND

Impaired self-awareness (ISA) has frequently been found to be both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

The present paper is the first of a two-part systematic review of ISA after traumatic brain injury (TBI), focusing on assessment methods, clinical aspects and recovery.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included.

RESULTS

ISA occurs in 30% to 50% of patients with moderate to severe TBI, although it tends to improve with time. There is no one single gold-standard measure of ISA. Self-proxy discrepancy scores, with scales such as the Patient Competency Rating Scale or the Awareness Questionnaire, or a structured interview such as the Self Awareness of Deficits Interview, are the most frequently used assessment methods, with adequate psychometric properties. Scores on these different scales correlate only moderately with each other, which suggests that they may address different aspects of self-awareness. ISA mainly concerns cognitive and behavioral problems rather than physical or sensory impairments and may concern different areas of functioning, such as anticipatory, emergent or meta-cognitive awareness.

CONCLUSION

ISA is a complex and multifaceted issue that should be systematically assessed in rehabilitation settings using a range of relatively well-validated tools. The consequences and predictors of ISA after TBI will be addressed in a companion paper.

Measuring domain-specific deficits in self-awareness in children and adolescents with acquired brain injury: Component analysis of the Paediatric Awareness Questionnaire

Self-awareness has been found to vary across different functional domains for adults with acquired brain injury (ABI); however, domain-specific self-awareness is yet to be investigated following paediatric ABI. This study aimed to validate the Paediatric Awareness Questionnaire (PAQ) as a multi-domain measure of self-awareness and to investigate domain-specific self-awareness in children with ABI. One hundred and ninety-seven children and adolescents (8-16 years, M = 12.44, SD = 2.62) with mixed causes of ABI (70% with traumatic brain injury) and their parents (n = 197) were recruited through consecutive rehabilitation appointments and completed the PAQ. The 37 items of the parent version of the PAQ were subjected to a principal component analysis with varimax rotation. A five-component solution (29 items) explained 64% of the variance in the PAQ items. Components revealed five domains of self-awareness: socio-emotional functioning, activities of daily living (ADLs), cognition, physical functioning, and communication. Internal consistency of the components ranged from acceptable to excellent (α = .70-.95). The analysis identified that children had poorer self-awareness of cognitive functioning than socio-emotional functioning, ADLs, and communication skills. Overall, the findings identify five components (i.e., functional domains) of self-awareness and provide some support that self-awareness varies across domains following paediatric ABI.

Awareness of cognitive abilities in the execution of activities of daily living after acquired brain injury: an evaluation protocol

INTRODUCTION

One of the main limitations that can be observed after acquired brain injury (ABI) is the alteration of the awareness of the deficits that can occur in the cognitive skills necessary for performing activities of daily living (ADL). According to the Dynamic Comprehensive Model of Awareness (DCMA), consciousness is composed of offline component, which contains the information stored about characteristics of the tasks and stable beliefs about one's own capabilities and online awareness, which is activated in the context of the performance of a specific task. The main objective of this project was to generate and validate a detailed cognitive assessment protocol within the context of ADL to evaluate the components of DCMA.

METHODS AND ANALYSIS

The proposed protocol consists of two ecological tools: The Cog-Awareness ADL Scale to measure offline component and the Awareness ADL-task: Basic and Instrumental ADL performance-based test to measure online awareness. The aim is to identify the presence of cognitive deficits and anosognosia in patients with ABI within the context of everyday life activities. These two measures will be administered to a group of patients with ABI. In addition, these participants will complete another series of classic tests on anosognosia and cognitive functions in order to find the convergent validity of the two tests proposed in this protocol. The external validity of the Cog-Awareness ADL Scale and the relationships between awareness components within the same ADL domain will be also analysed.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Biomedical Research of Andalusia, on 13 January /2017 (Proceeding 1/2017). All participants are required to provide written informed consent. The findings from this will be disseminated via scientific publication.

TRIAL REGISTRATION NUMBER

NCT03712839.

Evaluation of an occupation-based metacognitive intervention targeting awareness, executive function and goal-related outcomes after traumatic brain injury using single-case experimental design methodology

Self-awareness is commonly impaired after traumatic brain injury and impacts on rehabilitation engagement and community re-integration outcomes. Interventions which incorporate metacognitive strategy instruction have the potential to improve rehabilitation engagement and outcomes. This study aimed to determine whether an occupation-based intervention incorporating metacognitive strategy instruction resulted in goal achievement and improved online awareness and executive function performance during goal-related tasks. A single-case experimental design using a multiple-baseline design across behaviours was used with two participants with severe traumatic brain injury to evaluate the effectiveness of the 6-week intervention. Repeated measures of goal-related performance, percentage of self-corrected errors and executive function were made via independent analysis of video footage and documentation logs. Data analysis involved 2SD bandwidth analysis and overlap data, reliable change index and evaluation of goal achievement across phases. There were improvements in self-corrected errors for one participant, which were maintained. Significant reductions in anxiety (RCI = ±5.98) were evident for both participants, with a significant reduction in stress (RCI = ±7.05) for one participant following the intervention. The occupation-based intervention incorporating metacognitive strategy instruction led to improvements compared to baseline performance in some targeted goals, online awareness and executive function performance during goal-related tasks and reduced stress and anxiety.